An approach to feeding problems in infants and toddlers
Year: 2024
Type: article
Abstract: Opening Vignette Mrs. Chong brought her 7-month-old daughter, Chloe, to see you due to issues with weaning her child onto solids and Chloe’s recent refusal of bottle feeds. You learned that the pregnancy was planned, and Chloe had a normal birth history and no problems with latching on during breastfeeding previously. Mrs. Chong revealed that she has experienced a diminishing breast milk supply on returning to work and has been attempting to introduce formula feeds to Chloe. She also mentioned that when given purees, Chloe would make gagging sounds and spit out the food sometimes. Although Chloe has maintained her growth parameters on the 50th centile, Mrs Chong expressed concerns about her child’s growth and stress over having to ‘battle’ with her child during feeds.WHAT ARE FEEDING PROBLEMS? Feeding difficulty is a general term that covers all feeding problems regardless of cause, severity or consequences. This can range from mild forms of picky eating to a severe form of food refusal, such as those seen in children with autism spectrum disorder, requiring a multidisciplinary feeding team approach. Feeding disorders are defined as the inability or refusal to eat a sufficient quantity or variety of food to maintain adequate nutritional status, which can lead to malnutrition, impaired growth, emotional consequences and possible neurocognitive dysfunction.[1] Feeding disorders can be broadly divided into three main categories as follows:[2] Structural abnormalities: affecting the upper airway and the oesophagus Neurodevelopmental disabilities: disrupting the process of ‘learning to eat’ Behavioural feeding disorders (as defined by Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision)[3] HOW RELEVANT IS THIS TO MY PRACTICE? Feeding is an important part of the everyday life of infants and toddlers, and much parent–child interactions occur at feeding times.[2] About 25%–40% of infants and toddlers are reported by their caregivers to have feeding problems, which can range from purely behavioural issues (picky eating, refusing to eat) to problems manifesting with symptoms such as vomiting and pain. While only 1%–2% of infants aged <1 year have poor weight gain, 70% of these infants, if the problem is unaddressed, will continue to have feeding problems 4–6 years later. Not only does this have a significant impact on their long-term nutrition and cognitive development, but there is also a significant psychoemotional burden on their caregivers and the family unit. These children are also at a higher risk of developing further behavioural problems and eating disorders in their youth.[4] Locally, according to a questionnaire survey conducted in 2010 among Singaporean parents, about a quarter of the respondents perceived their child to have some form of ‘picky eating’, with the highest number first noticing their child’s picky eating behaviours or feeding difficulties as early as 1 year of age. It was also reported that all ‘picky eating’ and ‘feeding difficulty’ behaviours that occurred ‘all the time’ were significantly associated with caregiver stress during mealtimes and had a negative impact on family relationships.[5] Family physicians have an essential role in the detection, management and parental education of feeding issues in infants and toddlers. Identification of more complex cases is also crucial, as it allows for referral to a multidisciplinary team.[2] It is also common to see children with delayed developmental milestones in general practice, and up to 80% of infants with developmental delays have feeding problems.[6] In this article, we present a practical approach to children in the infant and toddler age group with feeding issues and attempt to answer some common clinical questions in daily general practice. WHAT CAN I DO IN MY PRACTICE? A structured medical approach is needed to address feeding problems in early childhood. A simple open-ended question during a routine review of the child may reveal parental concerns about feeding practices and underlying feeding problems. Any parental or caregiver concerns need to be taken seriously. Although not uncommon in general practice, failure to thrive (FTT) is not the only diagnostic criterion to be used when considering a child with a feeding disorder.[7] Clinical approach The clinical approach involves establishing the existence of feeding difficulties and ruling out any organic or behavioural red flag signs and symptoms that would warrant further specialist referral and assessment by a multidisciplinary team. These feeding problems can occur at any developmental stage of a child and in children who appear to be well nourished or even obese. Hence, it is imperative for the family physician to perform a comprehensive assessment. Feeding problem may be suspected when a child shows one or more of the following: (a) refusal of food for >1 month, (b) prolonged mealtimes, (c) stressful mealtimes, (d) distractions to increase intake, (e) lack of appropriate independent feeding, (f) prolonged breast or bottle feeding, (g) nocturnal feeding, and (h) failure to progress to advanced textures.[8] History Simple open-ended questions during a routine review may reveal feeding issues and parental concerns. The following are some suggested questions that could be asked:[1,2] Are there any feeding-related problems in your child? How does the feeding problem manifest during mealtime? Does the child have any known underlying illness that affects oral intake? Any concerns about the child’s growth and development? Any significant stress factors in the family? If any concern is raised, a comprehensive history should then be obtained [Box 1], and it must include dietary details, feeding-related behaviours, red flags’ symptoms and signs [Box 2], and age-appropriate developmental assessment. It is also important to include any significant antenatal and maternal history, the gestational age and any significant events at birth, previous hospitalisations, and the social and family setup at home [Boxes 1 & 2].Box 1: Suggested list of detailed questions to ask to obtain a comprehensive history.[ 1 ]Box 2: List of red flags.[ 8 ]Physical examination A review of growth parameters (i.e. height, weight and occipitofrontal circumference) is an essential part of any comprehensive assessment of feeding problems, as it can help to identify children with growth failure and alert the physician to a possible underlying organic cause.[9] A quick general examination would reveal the nutritional status and any associated dysmorphism. Physicians should look for any signs that might indicate neglect and child abuse. A complete neurological exam is mandatory, along with other targeted systemic examination, to rule out any organic causes.[2] A brief age-appropriate developmental assessment should also be done. Although observation of a mealtime interaction between the caregiver and the child may not be possible in the general practice setup, some of the interactive relationships between the child and the caregiver can be observed. For infants who have just started on solids, one should observe if the child is able to hold the neck steady and sit with support. Other things to look out for include drooling, an open mouth posture, abnormal breathing sounds and coughing. The physician should also examine the child for any structural abnormalities like cleft lip, cleft palate, tongue tie, poor dentition and enlarged tonsils, as well as check the tongue for painful ulcers or oral thrush and the nostrils for choanal atresia. Differential diagnosis When a child presents with certain signs and symptoms, it may point the clinician towards a particular differential diagnosis. These may be broadly classified into structural abnormalities, neurodevelopmental disabilities and behavioural feeding disorders [Box 3].[2]Box 3: Differentials classified into three main groups.WHAT INVESTIGATIONS SHOULD BE DONE? If a thorough assessment shows that the child has a normal physical examination, normal growth centiles and normal developmental assessment, then no further investigations are recommended.[1,2] If feeding problems have resulted in growth issues, then a thorough investigation is recommended. First-line investigations Full blood count with an iron panel (serum iron, iron-binding capacity, serum ferritin): to detect any iron-deficiency anaemia and thrombocytosis, which would indicate an ongoing chronic inflammatory process Renal panel, glucose: to detect any electrolyte abnormalities or evidence of dehydration as a complication of restricted eating Other electrolytes (e.g. calcium, magnesium and phosphate levels) and vitamin D: to detect any deficiency in electrolytes or vitamin D levels Liver function test: to look at the serum protein and serum albumin levels, which would give an indication of possible malnutrition Erythrocyte sedimentation rate: to detect any ongoing underlying inflammatory process. Second-line investigations Second-line investigations should be based on the physician’s clinical suspicion and can be undertaken at the specialist level.[2] They are as follows: Cow’s milk protein allergy: skin prick test to cow’s milk protein, serum immunoglobulin E to cow’s milk protein (level 1 evidence) Structural abnormalities in the gastrointestinal tract: upper gastrointestinal contrast study, oesophago-gastro-duodenoscopy (OGD) Gastro-oesophageal reflux: Oesophageal pH probe monitoring, only if patients do not respond to empirical treatment with acid suppressants. If severe, patients may need OGD to look for oesophagitis, strictures or webs[4] (level 2 evidence). Coeliac disease: anti-transglutaminase antibody, anti-endomysial antibody and total serum IgA followed by confirmatory intestinal biopsy Neurodevelopmental disabilities: brain imaging and further neurological assessment as clinically indicated WHEN SHOULD I REFER TO A SPECIALIST? When children are growing and developing at a normal tempo, physicians should reassure parents and explain that no further investigations are indicated at this point and the specific problematic behaviours noted should be addressed instead. If the associated symptoms are colic or occasional vomiting, but growth is not compromised, there is a role for a trial of dietary intervention. However, if there is presence of red flag symptoms or growth failure, it is recommended to refer the child for specialist evaluation and management.[2] WHAT ARE THE PRINCIPLES OF MANAGEMENT? Behavioural issues in the absence of growth problems If the infant is growing and developing normally and red flags have been excluded, it is important to provide reassurance to parents. Many first-time parents may be anxious and have questions regarding normal feeding behaviour, and so it is important to support them and equip them with knowledge on how to feed their child. There can be a range of different behaviours that are acceptable, and it is important for parents to first know the basic food rules that apply to all young infants and children [Boxes 4 & 5].[2,10,11,12,13] While children can decide how much they wish to eat to learn internal regulation or eating in accordance with the physiological signals of hunger and fullness, parents should be the ones to decide what to eat, and when and where mealtimes should take place. Positive parent–child interactions, such as eye contact, reciprocal vocalisations, praise and touch, should be encouraged, while negative interactions, such as forced feeding, coaxing, threatening and child’s disruptive behaviour (turning the head away from food, throwing food), should be strongly discouraged[2] [Boxes 4 & 5].[2,10,11,12,13] In addition to educating the parent on basic proper food rules,[2,10,11,12,13] there are certain strategies that can help to address more specific feeding problems. The strategies can broadly be divided into the categories discussed below.Box 4: Tips for breastfeeding/bottle-feeding infant.[ 10 , 11 , 12 ]Box 5: Rules applicable to children beyond infancy.[ 2 , 13 ]Limited appetite The physician can advise the parent on how to increase the caloric intake from the limited amount of foods consumed by the child. Fortification of milk (with an additional teaspoon of milk powder to 100 mL of breast milk) and fortification of solid food (with addition of butter, vegetable oil, cream or sauces) are simple ways to increase the caloric intake of the same total volume of food consumed by the child.[2] In case of severe behavioural problems and persistent FTT despite increasing the caloric intake, the child may need to be managed by a behavioural therapist, speech therapist and/or psychologist. Food selectivity It is normal for infants and toddlers to reject new food initially. Most will go on to accept these new foods after repeated exposure. Typically, foods must be offered at least 15 times to be accepted, as higher frequency of offering the new foods enhances acceptance in selective eaters.[14] For mildly selective children, simple strategies, such as hiding vegetables in other foods, modelling healthy eating, involving children in food preparation and so on, can be useful.[15,16,17,18] Children who are highly selective, particularly those with severe oral aversion or autism, would benefit from seeing a behavioural therapist and an oromotor therapist.[8] When introducing new foods, it should be done singly and not during intercurrent illness, and parents should persevere and present the new food day after day until the child gets used to it. Toddlers will accept new food more easily if they witness their parents eating it.[4] Fear of feeding This may be caused by an event such as choking, gagging or vomiting, or due to an organic condition that causes odynophagia. Apart from treating any underlying organic cause, the main principles of treatment are reassurance, systematic appraisal and treatment of the causes of discomfort, and alleviating the feeder’s anxiety.[8] In young infants, starting with a sleep–feeding schedule to help maintain adequate nutrition may be essential in the beginning. Subsequently, the feeding environment and equipment may be altered to improve acceptance of foods. For infants who truly reject the bottle or breast, earlier transition to cup feeding or solids may be necessary. For older children with moderate to severe symptoms, reassurance is key to recovery. If fear is persistent, a psychologist or psychiatrist may need to be involved.[8] Infantile anorexia In situations where the parent–child dyad becomes involved in conflicting interactions, with a struggle for control and food being the battleground, the suggested interventions involve helping the parent to understand their child’s special temperament and triggers. It is important to advise the parent to set clear limits and structure to mealtimes to facilitate the internal regulation of eating and counteract the external regulation produced by emotional interactions within the caregiving environment.[2] Symptomatic children in the absence of growth problems In cases of colic and occasional vomiting, a trial of dietary intervention can be carried out by the physician.[2] Maternal elimination of allergenic foods, such as dairy products, eggs, nuts, fish, soy and wheat, could be trialled in fully breastfed infants, while hypoallergenic formula can be given to bottle-fed infants to help reduce or relieve the symptoms of colic, particularly in children with a strong personal or family history of atopy. A diagnosis of food allergy should not be made, however, unless the symptoms are reproducible upon reintroduction of the eliminated food. If vomiting and irritability persist despite the above measures, a trial of acid suppression or prokinetic agents may help relieve or reduce the symptoms, as there is often an overlap between cow’s milk protein allergy and gastro-oesophageal reflux.[19] Acid suppressants, which include antacids, histamine H2 antagonists and proton pump inhibitors, are more commonly used because of growing evidence that they are more effective than prokinetic agents. However, there is concern of overprescription of acid suppressants, especially proton pump inhibitors; hence, chronic antacid therapy is generally not the first-line recommendation to treat gastro-oesophageal reflux in such children. There are also nonpharmacological measures, such as positioning, thickening feeds, and smaller and more frequent feeds, which can help significantly with symptoms of gastro-oesophageal reflux. Children with feeding and growth problems It is important to address the underlying organic cause that has resulted in the feeding issue, which is beyond the scope of this article. However, it is important to note that even with optimal medical management of their underlying condition, children with concomitant medical conditions often continue to have feeding problems that persist, such as eating slowly, food refusal and being demanding and difficult at mealtimes. Under these conditions, the basic food rules [Box 5] and behavioural interventions should be considered. Some behavioural interventions that the parents can adopt include setting clear time limits for meals, ignoring noneating behaviour, and using active praise and positive reinforcement to motivate their children to meet the food intake goals set. However, for more severe symptoms, referral to a tertiary centre is warranted, so that a multidisciplinary team consisting of a paediatrician, dietitian, speech and language or oromotor therapist, occupational therapist and psychologist can conduct further investigations and provide treatment. TAKE-HOME MESSAGES Feeding problems can occur even in infants and toddlers with normal growth and development. Most cases of feeding problems are due to behavioural issues in the infant and toddler. Some feeding problems may be due to an underlying structural abnormality or an undiagnosed neurological disorder; a thorough assessment is important on top of monitoring the growth parameters. When infants and toddlers are assessed to be growing and developing normally, primary care physicians should reassure parents and explain that no further investigations are indicated at this point in time. If growth is a concern, a referral to a specialist is warranted for further evaluation as indicated. It is essential for the primary care physician to understand the basic food rules and tips for a breastfed or bottle-fed infant. Closing Vignette Chloe was found to be growing well along her centiles with no evidence of concern in her height, weight or occipitofrontal circumference. She was also assessed to be developmentally meeting the appropriate milestones for her age, displaying good head and truncal control, as well as demonstrating good suck–swallow–breathing coordination when she drank water from her bottle. Her gagging on eating pureed food was found to be an exaggerated gag reflex, which will improve with gradual increased exposure to solid food. As such, you assured Mrs. Chong that there was no indication for any further investigation. You also advised her to continue exposing her daughter to formula feeding via a bottle with an appropriately sized bottle teat, and to do so comfortably in a calm and positive environment. Mrs. Chong was reassured knowing that her daughter’s growth was not compromised and felt more her bottle refusal at home with more and and for her support. support and of There are no of for 10
Source: Singapore Medical Journal
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4405408819